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Brachial Plexus Block
Above the Clavicle
Edited by
Dr. M Dorgham
Under supervision of
Proff Dr. Amr Abdelfattah
Objectives
Review the Anatomy of brachial plexus
Neurostimulation guided approaches
Sonoanatomy and Ultrasound guidance
Complications
Advantages of ultrasound guidance
Anatomy of Brachial Plexus
•The brachial plexus is a network of nerve fibers , running from the spine,
formed by the ventral rami of the lower four cervical and first thoracic nerve
roots (C5-T1). It proceeds through the neck, the axilla (armpit region), and
into the arm.
•The brachial plexus is responsible for cutaneous and muscular innervation
of the entire upper limb, with two exceptions:
The trapezius muscle innervated by the spinal accessory nerve (CN XI)
and
An area of skin near the axilla innervated by the intercostobrachial
nerve.
Anatomy of Brachial Plexus
The brachial plexus is divided into
Roots
Trunks
Devisions
Cords
Branches
Anatomy of Brachial Plexus
Nerve
Roots
Muscles
Roots
Dorsal scapular
nerve
C5
Rhomboid
Levator scapulae
Roots
Long thoracic nerve
C5 C6 C7 Serratus anterior
Cutaneous
Anatomy of Brachial Plexus
Nerve
Roots
Upper
Trunk
Nerve to subclavius
C5 C6
Upper
Trunk
Suprascapular nerve C5 C6
Muscles
Subclavious
Supraspinatous
Infraspinatous
Cutaneous
Anatomy of Brachial Plexus
Nerve
Roots
Muscles
Cutaneous
Lateral
cord
Lateral pectoral
nerve
C5 C6 C7 Pectoralis Major
By
communication
with Medial
Pectoral Nerve
Lateral
cord
Musculocutaneous
nerve
C5 C6 C7 Coracobrachialis Become the
Brachialis
Lateral
cutaneous
Biceps brachii
nerve of
forearm
Lateral
cord
Lateral root of
median nerve
C5 C6 C7 Fibres of Median
nerve
Anatomy of Brachial Plexus
Nerve
Roots
Muscles
Cutaneous
Medial
cord
Medial pectoral Nr
C8 T1
Pectoralis major
Pectoralis minor
Medial
cord
Medial root of
median Nr.
C8 T1
Fibres to
median nerve
Medial
cord
Medial cutaneous
nerve of arm
C8 T1
front and medial
skin of the arm
Medial
cord
Medial cutaneous
nerve of forearm
C8 T1
medial skin of
the forearm
portions of hand
not served by
ulnar or radial
Anatomy of Brachial Plexus
Medial
cord
Ulnar Nr.
C8 T1
1. Flexor carpi
ulnaris
2. the medial
two bellies of
flexor
digitorum
profundus,
3. the intrinsic
hand muscles
except the
thenar muscles.
4. the two
most medial
lumbricals
the skin of the
medial side of
the hand
medial one and
a half fingers on
the palmar side
medial two and
a half fingers on
the dorsal side
Nerve
Roots
Muscles
Cutaneous
Post
cord
Upper subscapular
nerve
C5 C6
Sub scapilaris
(upper part)
Post
cord
Thoracodorsal Nr
(Middle subscapular)
C6 C7 C8
Latismus Dorsi
Post
cord
Lower scapular Nr
C5 C6
Subscapularis
(lower part)
Teres major
Post
cord
Axillary Nr.
C5 C6
Ant Br: Deltoid
& small area of
overlying skin
Post Br: Teres
minor &
Deltoid ms
Post Branch
continues as
upper Lateral
cutaneous Nr of
arm
Post
cord
Radial Nr.
C5 C6 C7
C8 T1
Triceps brachii
Supinator
Anconeus
Brachioradialis
Extensors of
forearm
Posterior
cutaneous
nerve of arm
INTERSCALENE BLOCK
ANTERIOR APPROACH
Superficial anatomy
Superficial anatomy
The sternal head of the sternocleidomastoid muscle (1) is anterior to its
clavicular head (2), which forms the anterior border
of the posterior triangle of the neck.
The accessory nerve (3) is superficial to the fascial floor of the posterior triangle
of the neck and originates close to the
lesser occipital nerve (4).
The superficial cervical plexus (5) is superficial to the fascial floor
of the posterior triangle of the neck and gives rise to the
supraclavicular nerves (6). The superficial cervical plexus originates
from C2 and supplies the ipsilateral skin of the neck, shoulder and occipital area
with sensory fibers.
The trapezius muscle (7) is innervated by the accessory nerve (3), and the
nerve to levator scapulae innervates the levator scapulae muscle (8).
Deep anatomy
Deeper anatomy
A view of the anatomy with the sternocleidomastoid muscle removed shows the position
of the
internal jugular vein (1) (cut off here). Deep to the internal jugular vein is the
thoracic duct (2) on the left side of the neck and adjacent to that the
Anterior scalene muscle (3). Posterior to that is the
middle scalene muscle (4) and more posterior,
the posterior scalene muscle (5). Posterior to the posterior scalene muscle is the
levator scapulae muscle (6) with the
nerve to the levator scapulae muscle (7).
The accessory nerve (8) as well as the
trapezius muscle (9) can be seen. Also note the
vagus nerve (10), which is situated in close relationship to the
carotid artery (11), and the
phrenic nerve (12), which is situated on the belly of the anterior scalene muscle (3). The
brachial plexus (13) is situated between the anterior and middle scalene muscles. The
suprascapular nerve (14) and the
dorsal scapular nerve (15) (which innervates the rhomboid muscles) branches from the
brachial plexus. Note that the
subclavian artery (16) lies anterior to the brachial plexus.
Surface anatomy
1 = Phrenic nerve
2 = Brachial plexus
3 = Dorsal scapular nerve (to rhomboid
muscles)
4 = Nerve to levator scapulae
POSTERIOR APPROACH (OR
CONTINUOUS CERVICAL PARAVERTEBRAL BLOCK)
The continuous cervical paravertebral block is ideal for relief of postoperative pain
following shoulder surgery, especially arthroscopic shoulder surgery.
This approach sometimes does not involve the nerves of the superficial cervical plexus
and the skin around the shoulder area will therefore not be anesthetized.
Although not yet evaluated by formal research, the experience of this author is that loss
of resistance to air as well as nerve stimulation may be used for the placement in this
block. If proven successful, this should make this block ideally suited for postoperative
use, and when severely painful conditions such as fractures of the shoulder are present
where nerve stimulation is not advisable or impractical.
Anatomy
The brachial plexus (1) is situated between the anterior (2) andmiddle (3) scalene
muscles, while the vertebral artery (4) is guarded by the bony structures of the
vertebrae.
The posterior approach for ISB is antero-lateral to the trapezius muscle (5) and
postero-medial to the levator scapulae muscle (6).
Anatomy
The point of needle entry is in the apex of the “V” formed by the
trapezius muscle posterior and the levator scapulae muscle anterior –
the “B”-spot
Surface anatomy
Needle entry should be at the level of C6 and just antero-lateral to the trapezius muscle
and postero-medial to the levator scapulae muscle in the apex of the “V” formed by
these two muscles.
Needle placement
The nerve stimulator is clipped to the needle and a loss-of-resistance to air device is
placed on the needle. The needle is directed , anteriorly and caudad, aiming for the
suprasternal notch.
The needle is carefully “walked off” the transverse process of C6 and loss of
resistance to air and muscle twitches of the shoulder girdle appear
simultaneously.